Wednesday, June 29, 2011

Curbing the narcotic problem

By now you have probably heard about the Father's Day incident on Long Island that left two pharmacy employees and two customers dead, victims of an armed robbery. Apparently the gunman was trying to obtain controlled substances for his wife.

If you run over to Google and search for "pharmacy" in the news, you'll get a steady stream of stories about robberies and thefts at the pharmacy. A few weeks ago, up until the Long Island incident, the pharmacy stories revolved around the murder conviction of an Oklahoma pharmacist who emptied his gun into a man who had attempted to rob his pharmacy.

Around the same time there were stories floating around about a Michigan pharmacist who fought back against some robbers, unloading his weapon during a middle-of-the-night robbery. He was subsequently terminated for his actions.

These aren't the headlines we want to see for the profession of pharmacy. But the reality that we face today is that there are many addicts in this county, and they are becoming bolder in their attempts to obtain controlled substances. Pharmacies are the places who the controlled substances are, therefore pharmacies are the targets.

What are the reactions to these events? New York Senator Chuck Schumer has come out with a plan to require prescribers to undergo additional training before being able to prescribe narcotics like Vicodin and Percocet. His plan also calls for increased penalties for people who rob pharmacies.

Prior to the Long Island incident, the APhA (in Pharmacy Today) was reporting on the White House's plan to curb prescription drug abuse. For the last several months we've heard about the opioid REMS (Risk Evaluation and Mitigation Strategies) requirements that have been in the works.

The opioid REMS program calls for voluntary physician training when it comes to prescribing opiates (although there is talk of linking training to DEA registration). It also calls for pharmacists to distribute a MedGuide along with each prescription for the affected products.

Other projects/programs that are being used to help curb the abuse of narcotics include prescription drug monitoring programs (the one in my state is not real-time, it has a two-week lag), prescription drug take-back days, and Cephalon's when good medicines become bad drugs program.

As a practicing pharmacist, these programs do absolutely nothing to stop the abuse of narcotics. Anybody who works in community pharmacy knows how people will do or say anything to get their drugs. I honestly don't think handing a patient an extra sheet of paper telling them how the opiates might be bad for them will really affect their efforts to obtain morphine. A coloring book for kids isn't going to keep an addicted mom from deceiving a clinic physician in an attempt to score some hydrocodone. These programs may make non-practicing pharmacists feel good about doing something to curb the narcotic problem, but do they really do anything? In my opinion, the answer is no.

So what is the solution?

There isn't one. But that doesn't mean that steps can't be taken to attempt to slow things down. The solution isn't one that falls strictly to the medical and pharmacy professions. It includes law-enforcement and the federal government. I won't go into the details of what the cops and feds should do, let's just say that they needs to be involved even more than they are.

For those of us in the medical professions, we need to have real-time information provided to us, as well as having security measures in place for the protection of the employees at the pharmacy.

When a patient visits a prescriber, there needs to be a means to relay to the pharmacy what was actually prescribed. We've all had somebody present a prescription for Percocet or Vicodin from the ER late on a Saturday. In your gut you know that there was a second prescription issued, but somehow it was lost between the ER and the pharmacy counter.

As much as I hate the thought of a centralized database, I propose a centralized database that records everything that has been prescribed as well as what has actually been filled for a patient. The process is simple... any time that you visit a prescriber you must present your identification card. The prescriber swipes the card thru a reader and is able to see what meds you have been prescribed, who prescribed them, what you actually had filled, and where you had it filled.

Before releasing you with your prescription, the prescriber would record what medications they were prescribing and upload it to the database. When the patient visits the pharmacy, they would hand over both their prescriptions and the identification card. The pharmacist would be able to see what the patient should be having filled and compare it to what is actually being filled. If you don't present all of the scripts or only request the narcotics, the pharmacist records it in the database. That way future prescribers and pharmacists have a better picture of the behaviors that a particular patient has used. Ideally diagnosis codes would be included as well, so all of the health care system would know what the patient's chief complaints have been.

I would like to see the diagnosis code be a required part of the prescription, similar to Medicare B testing supplies. When a prescription is filled, the DEA number, NDC number, quantity, and diagnosis code would be transmitted to the DEA. That way the DEA could track (in real time) which prescribers are ordering which medications for particular diagnoses. A family practice physician who suddenly starts prescribing 720 oxycodone 15s, 120 Percocets, and 60 Oxycontin 80s to every third patient for chronic lower back pain could be stopped before they draw every addict in a fifty mile radius to their practice.

Those steps may help to lessen the chances of creating addicts, but the pharmacies need to be protected from the current addicts. This is where it gets a bit dicey. Pharmacists wear it as a badge of honor that we are the most accessible health care provider. But I don't think any of us want to see our accessibility lead to the death or injury of another pharmacy worker.

I have absolutely no problem with the thought of working behind bulletproof glass. Heck, I'd work out of a bank vault with drawer (similar to a drive-thru set-up) if it means keeping my staff safe. Time-delay safes for narcotics...absolutely. No narcs after 6 PM...sounds good. I've had armed guards escort me from the pharmacy lab to the front door before, then watch me from the door as I've crossed the parking lot to get to my car. If it keeps me safe, I'm for it.

Anyhow, it's getting late for me. I thought I'd share some of my thoughts on the narcotic problem that is affecting our profession as well as offer up some solutions. What are your thoughts?

Tuesday, June 28, 2011

Test post

This is a test of the feature that allows me to publish posts by simply sending an email to a specific address. This could come in handy if I have the desire to develop and type an entire entry from my phone.

There is no content related to the profession of pharmacy in this post. I am working on a few ideas and should have an actual, substantive post in the near future.

As an aside, I have been busy getting ready for my change from community pharmacy to hospital pharmacy. Only six more retail shifts remain after today. I am excited for the move, especially since the main medical practice group at the hospital wants me to get an anticoagulation clinic up and running in the near future.

This concludes today's test post.
Eric Durbin

Wednesday, June 22, 2011

Thoughts on prescription volume and liability for errors

Imagine if you will the following scenario... district manager calls the pharmacy to speak with the pharmacy manager. A short conversation ensues where the pharmacy manager is speaking in a hushed voice and starts to look frustrated. After the call, the pharmacy manager pulls the other pharmacist(s) aside and tells them that corporate has determined that the pharmacy volume isn't high enough to support the pharmacist staffing and, as a result, pharmacist hours are going to be cut.

Imagine that at the current staffing levels, each pharmacist is verifying an average of twenty prescriptions per hour. That is on top of counseling patients, making OTC recommendations, talking to physicians and nurses on the phone, resolving third-party issues, evaluating DURs, etc... Three minutes per prescription without those distractions isn't that much time.

Imagine that the new staffing algorithm calls for pharmacists to verify (on average) twenty-five prescriptions per hour. Two minutes, twenty-four seconds per prescription. Not counting the distractions. If I look up the word disaster in the dictionary, I might see this as an example.

In the sixteen years that I have been a pharmacist, the profession has devolved from what was once a medical profession that took care of patients to a fast-food operation that wants to see how many customers they can get thru the doors. Pharmacists who work in this environment are afraid to speak up out of fear of losing their jobs.

What has led our profession to this? Several factors come into play.

Corporate ownership of pharmacies is a biggie. When the people who make decisions about the operations of the pharmacy don't actually work in a pharmacy, there is a major disconnect. It's even worse when the managers making these decisions aren't even pharmacists. I've had managers who have been pharmacists and managers who aren't pharmacists. At least the pharmacists have some idea of the realities of the profession, even if they have sold out as they have moved up the corporate ladder.

Declining third-party reimbursements. The argument is that declining margins mean that more scripts must be filled to make the same profits as before. There is a simple solution... stop signing contracts that don't reimburse at a respectable level. Everybody seems to be afraid of turning away people if we don't accept their plan. Hoping to make up for the horrible reimbursements on the prescriptions by selling a extra tube of toothpaste as an impulse buy. I was able to obtain a copy of a third-party contract at my previous employer. The terms for generic medications were AWP- 25% + 1.75 for 30 day supplies. AWP- 50% + 0.00 on 90 day prescriptions. And the employer was pushing us to get the people on 90 day prescriptions. ???

Four dollar/free prescriptions. Apparently the corporates offering these programs aren't afraid of telling you exactly how much they value your training and expertise. Nuff said.

Surplus of pharmacists. Remember 15 years ago when there was a pharmacist shortage? Then all the new pharmacy schools opened up. And now the job market is flooded. Remember how companies used to treat pharmacists well in order to keep them? Now pharmacists willingly accept being treated as highly-trained monkeys in order to remain employed.

Pharmacists need to stop being so timid when addressing issues with the members of management who are making the decisions that are destroying the profession. It's not their license and livelihood that is on the line if a mistake is made. It's yours. If you won't speak up for yourself, who will?

We need to remember that we are medical professionals first and foremost. We are liable for any and all errors that may occur in the pharmacy. Some pharmacists are lulled into a false security when employers say that they will carry a liability policy to cover the pharmacists. The policy that stipulates that all policies and procedures must be followed exactly or else the coverage is not valid. I'm guessing that it takes longer than two minutes, twenty-four seconds to follow the policies and procedures on each prescription.

This is just a thought on the subject, but the next time there is a major error that occurs due to a pharmacist being required to fill too many prescriptions per hour/shift, I'd like to see some other defendants in the courtroom. Instead of just the pharmacist and maybe the corporate being named in a lawsuit, I'd like to see the district manager, regional manager, and everyone up the corporate ladder all the way to the CEO being named in the case. Maybe if the members of management who make these staffing decisions are held just as liable for errors as the pharmacists in the field, we may see some changes.

Wednesday, June 15, 2011

Here is more from my conversation with a fellow frustrated pharmacist. I find some of his insights very interesting. Again, what are your thoughts? Please share them here for everybody's benefit. I appreciate the emails, but more people see your thoughts when they are in the comments and not my email inbox.

I just read part of your note to Jim. Anybody that says they are an expert in MTM is not being entirely straightforward, in my opinion. If there were such a person and he/she knew how to do it and make it meaningfully profitable, they should be shot if they keep that information to themselves. People may be experts in "MTM" if they have charts available but they are still not managers of drug therapy in the sense Hepler and Strand meant it. We are not given and don't have the right to be responsible to the patient for drug therapy. That still rests with the doctor--we would need an OK from each MD and that's not what Hepler and Strand meant. But what they meant is extremely unlikely to ever occur (my opinion). The Ashville Project was and is such an artificial situation, I'm not surprised they can't give you an exact amount the pharmacists were paid. It was something that evolved over time. At first, the pharmacists spent varying amounts of time and their documentation was very sloppy as to what they actually did. They were also assisted by a diabetes nurse educator who did alot of what we would hope to bill as MTM. They also had a leading community physician running as a front man for them to help get physicians reluctant acceptance and several hospitals, as I recall, were also involved. I'm relying on memory of articles I read about 7 or 8 years ago that I have since thrown out (along with my hope of MTM ever being a working model). I don't know that academia and APhA are actually keeping anything from you so much as they probably really don't have precise figures and the services/types, records, etc varied over the years. Pfizer is now a major sponsor of Ashville and I wouldn't believe anything Pfizer had input on anyway. They back the PBM's and we know what the PBM's think of retail pharmacy. We are fighting against billions of dollars and some of those dollars have been used to compromise APhA. In my opinion, APhA tries to sound like pharmacists is who they represent, but the real money comes from large pharmaceutical corps. that they must feel they can't afford to piss off. Look at the response Tom M. (APhA exec. VP) gave to David Stanley's editorial, "You Talkin' For Me?" in Drug Topics. He barely hid his hostility. He brushed aside David's points and essentially accused him of not knowing how to use technology or technicians. He referred to him as "Stanley" every time he mention David's name except the first time when he called him "David Stanley." I got no sense that he felt he was talking to a colleague but to someone that pissed him off by telling the truth.

Friday, June 10, 2011

Frustrated with pharmacy

There are times when I get frustrated with my profession, as I'm sure you do too. This blog has enabled me to make connections with pharmacists from all over the world. A few months ago I had an email conversation with a fellow pharmacist who is frustrated. I was actually looking into other career options at that time.

The following is copied/pasted from one of the emails. I have permission to share this from the other pharmacist.

What are your thoughts? Are you as frustrated with your profession as this pharmacist is?

My quest is to get out of pharmacy too. I went back to graduate school at age 53 and got a Masters in Mental Health Counseling with an AODA concentration. I graduated 3 years ago and have had to stay in pharmacy to pay the bills for graduate school. My wife is about to start a job as a nurse and if I could find a job at $60,000 per year I'd be gone tomorrow. I've done AODA counseling as part of our graduate training. The satisfaction I get from working with alcoholics and addicts is way beyond any satisfaction I have gotten from pharmacy. Plus, we actually use much of what we were taught in school. What a novel idea. With the economic downturn, finding an AODA job in my area (NE Wisconsin) is tight but I keep looking and hoping. Good luck in your quest. Do you know why they call it the "Asheville Project"? OK, neither do I but one of the reasons has to be because it never ever came close to reaching the controls necessary to qualify it as a study. That pharmacy would trumpet it as "evidence" of anything is further proof of how little proof MTM has as a viable model. In graduate school, I had to take a stats course and several research courses. "Asheville" as a study would have little internal or external validity because there were so many variables that were not controlled (confounders) and its widespread applicability (generalizability or external validity) to other practice types is extremely low. To answer your question as to where the MTM model came from, it was a paper Hepler and Strand wrote in approx 1990 about pharmaceutical care and its application, MTM. Only someone in pharmacy would consider it even a remotely possible practice model. Unfortunately, all pharmacy schools subsequently did. Now we have Doctors taking orders from Med Techs--they had to come up with a degree appropriate to all the new responsibilites pharmacists would have--hence, the 6 yr. PharmD. If I was a PharmD, I'd be pissed.

Tuesday, June 7, 2011

Prescriptions per hour

I recently posted a poll that asked the following question:

How many prescriptions can a pharmacist fill safely per hour (including counseling)?

The results did not surprise me:
  • 0-10 (10%)
  • 11-15 (44%)
  • 16-20 (30%)
  • 21 or more (16%)
The majority felt that 11-15 scripts per hour was the safe level. At that rate, you have 4 to 6 minutes per prescription to verify the accuracy of the prescription label, check the patient profile for duplications/interactions, contact prescribers if any issues arise, call the insurer if needed, verify that the contents of the prescription vial are accurate, and counsel the patient on their medication.

Not included in this 4 to 6 minute span are the interruptions that a pharmacist must deal with. A patient asking for an OTC recommendation. Phone-in prescription from a prescriber's office. Phone ringing from a patient phoning in refills (I actually think that there is a rule somewhere that requires a pharmacy to have two more phone lines than people working in the pharmacy).

But back to what we actually do. We rely on the DUR software to help us check for interactions, but a recent study from the University of Arizona found that the software systems are flawed (link here). That means that we, as pharmacists, should dig through a patient's profile each and every time that we fill a prescription to check for interactions. That takes time.

Another part of the prescription process that take time is counseling. From my experience and observations, pharmacists fail at this horribly. I watch how pharmacists counsel patients on their prescriptions. 95% of the time "counseling" is simply the pharmacist reading the label to the patient. OBRA '90 gave us specific points that we are to cover when we counsel the patients.

OBRA ’90 Counseling Points:
  • Name of drug.
  • Intended use and expected action.
  • Route, dosage form, dosage, and administration schedule.
  • Common side effects that may be encountered,including their avoidance and action required if they occur.
  • Techniques for self-monitoring of drug therapy.
  • Proper storage instructions for the medication.
  • Potential drug-drug or drug-food interactions or other therapeutic contraindications.
  • Prescription refill information.
  • Action to be taken in the event of a missed dose. (source)
To inform a patient on all of these points, time is required. Two or three minutes, per prescription, is what I feel is adequate to ensure that the patient understands what I am saying. Then you need to allow time for questions from the patient.

* * * * *

So I found it amusing recently when upper management decided to change the guidelines for the number of prescriptions a pharmacist should fill on an hourly basis. I'll just say that, prior to the change, we were at the higher end of the volume spectrum of the poll. The new guidelines call for an increase of 25 percent.

I contacted my state board of pharmacy, whose mission statement states that it is to the public interest to pursue optimal standards of practice through...legislation, licensing and enforcement to see what their take on my employer's changing guidelines were. The response from my pharmacy board was that no prescription volume limits have been or are being considered. Apparently my pharmacy board believes that a maximum time of two minutes, 24 seconds per prescription is the optimal standard of practice.

Eric Cropp lost his pharmacist license permanently due to a dispensing error. He was in a situation where there was too much work to be done with inadequate staffing. The little girl who was undergoing her last chemo treatment ended up dead from the error. So when he speaks about the rapid pace of pharmacy and the potential for error, I'm paying attention. He was quoted in a recent internet article as saying "We want to stress the fact that everybody's got to slow down and treat each patient like they're a member of your family...Healthcare is so fast and crazy sometimes we start to miss the fact that we're taking care of a human being, not running an assembly line."

If only the management of the pharmacy chains would think the same way.

Friday, June 3, 2011

Summer safety

I posted this on Twitter a couple days ago. After mulling it over in my head, I decided that these Tweets were worthy of their own blog post.

This will be short and to the point. And it may save suffering for your patients over this summer.

Feel free to print this out and post it at your pharmacy for your patients/customers to read.

* * * * *

This is the sun. If you can see it, put on some sunscreen.

For the folks who get poison ivy every year. This is what it looks like. DON'T TOUCH IT!

Now that I have said that, go outside and enjoy the summer.